The nurse knows that which statement by the mother indicates
that the mother
understands safety precautions with her four month-old infant
and her 4 year-old child?
A) "I strap the infant car seat on the front seat to face backwards."
B) "I place my infant in the middle of the living room floor on a
blanket to play with my
4 year old while I make supper in the kitchen."
C) "My sleeping baby lies so cute in the crib with the little
buttocks stuck up in the air
while the four year old naps on the sofa."
D) "I have the 4 year-old hold and help feed the four month-old a
bottle in the kitchen
while I make supper."
The correct answer is D: "I have the four year-old hold and help
feed the four month-old
a bottle in the kitchen
When admitting a client to an acute care facility, an
identification bracelet is sent up
with the admission form. In the event these do not match, the
nurse’s best action is to
A) Change whichever item is incorrect to the correct information
B) Use the bracelet and admission form until a replacement is
supplied
C) Notify the admissions office and wait to apply the bracelet
D) Make a corrected identification bracelet for the client
The correct answer is C: notify the admissions office and wait to
apply the bracelet
The nurse is having difficulty reading the health care provider's
,written order that was
written right before the shift change. What action should be taken?
A) Leave the order for the oncoming staff to follow-up
B) Contact the charge nurse for an interpretation
C) Ask the pharmacy for assistance in the interpretation
D) Call the provider for clarification
The correct answer is D: Call the provider for clarification
An adult client is found to be unresponsive on morning
rounds. After checking for
responsiveness and calling for help, the next action that should
be taken by the nurse is
to:
A) check the carotid pulse
B) deliver 5 abdominal thrusts
C) give 2 rescue breaths
D) open the client's airway
The correct answer is D: open the client''s airway
A client has an order for 1000 ml of D5W over an 8 hour
period. The nurse discovers
that 800 ml has been infused after 4 hours. What is the priority
nursing action?
A) Ask the client if there are any breathing problems
B) Have the client void as much as possible
C) Check the vital signs
D) Auscultate the lungs
The correct answer is D: Auscultate the lungs
Following change-of-shift report on an orthopedic unit,
which client should the nurse
see first?
,A) 16 year-old who had an open reduction of a fractured wrist
10 hours ago
B) 20 year-old in skeletal traction for 2 weeks since a motor cycle
accident
C) 72 year-old recovering from surgery after a hip replacement
2 hours ago
D) 75 year-old who is in skin traction prior to planned hip pinning
surgery. The correct answer is C: 72 year-old recovering from
surgery after a hip replacement 2
hours ago
A nurse observes a family member administer a rectal
suppository by having the
client lie on the left side for the administration. The family
member pushed the
suppository until the finger went up to the second knuckle. After
10 minutes the client
was told by the family member to turn to the right side and the
client did this. What is the
appropriate comment for the nurse to make?
A) Why don’t we now have the client turn back to the left side.
B) That was done correctly. Did you have any problems with the
insertion?
C) Let’s check to see if the suppository is in far enough.
D) Did you feel any stool in the intestinal tract?
The correct answer is B: That was done correctly. Did you have
any problems with the
insertion?
A client with a diagnosis of Methicillin resistant Staphylococcus
aureus (MRSA) has
, died. Which type of precautions is the appropriate type to use
when performing
postmortem care?
A) airborne precautions
B) droplet precautions
C) contact precautions
D) compromised host precautions
The correct answer is C: contact precautions
A nurse administers the influenza vaccine to a client in a
clinic. Within 15 minutes after
the immunization was given, the client complains of itchy and
watery eyes, increased
anxiety, and difficulty breathing. The nurse expects that the first
action in the sequence of
care for this client will be to
A) Maintain the airway
B) Administer epinephrine 1:1000 as ordered
C) Monitor for hypotension with shock
D) Administer diphenhydramine as ordered
The correct answer is B: Administer epinephrine 1:1000 as ordered
.
Which of these children at the site of a disaster at a child
day care center would the
triage nurse put in the "treat last" category?
A) An infant with intermittent bulging anterior fontanel
between crying episodes
that the mother
understands safety precautions with her four month-old infant
and her 4 year-old child?
A) "I strap the infant car seat on the front seat to face backwards."
B) "I place my infant in the middle of the living room floor on a
blanket to play with my
4 year old while I make supper in the kitchen."
C) "My sleeping baby lies so cute in the crib with the little
buttocks stuck up in the air
while the four year old naps on the sofa."
D) "I have the 4 year-old hold and help feed the four month-old a
bottle in the kitchen
while I make supper."
The correct answer is D: "I have the four year-old hold and help
feed the four month-old
a bottle in the kitchen
When admitting a client to an acute care facility, an
identification bracelet is sent up
with the admission form. In the event these do not match, the
nurse’s best action is to
A) Change whichever item is incorrect to the correct information
B) Use the bracelet and admission form until a replacement is
supplied
C) Notify the admissions office and wait to apply the bracelet
D) Make a corrected identification bracelet for the client
The correct answer is C: notify the admissions office and wait to
apply the bracelet
The nurse is having difficulty reading the health care provider's
,written order that was
written right before the shift change. What action should be taken?
A) Leave the order for the oncoming staff to follow-up
B) Contact the charge nurse for an interpretation
C) Ask the pharmacy for assistance in the interpretation
D) Call the provider for clarification
The correct answer is D: Call the provider for clarification
An adult client is found to be unresponsive on morning
rounds. After checking for
responsiveness and calling for help, the next action that should
be taken by the nurse is
to:
A) check the carotid pulse
B) deliver 5 abdominal thrusts
C) give 2 rescue breaths
D) open the client's airway
The correct answer is D: open the client''s airway
A client has an order for 1000 ml of D5W over an 8 hour
period. The nurse discovers
that 800 ml has been infused after 4 hours. What is the priority
nursing action?
A) Ask the client if there are any breathing problems
B) Have the client void as much as possible
C) Check the vital signs
D) Auscultate the lungs
The correct answer is D: Auscultate the lungs
Following change-of-shift report on an orthopedic unit,
which client should the nurse
see first?
,A) 16 year-old who had an open reduction of a fractured wrist
10 hours ago
B) 20 year-old in skeletal traction for 2 weeks since a motor cycle
accident
C) 72 year-old recovering from surgery after a hip replacement
2 hours ago
D) 75 year-old who is in skin traction prior to planned hip pinning
surgery. The correct answer is C: 72 year-old recovering from
surgery after a hip replacement 2
hours ago
A nurse observes a family member administer a rectal
suppository by having the
client lie on the left side for the administration. The family
member pushed the
suppository until the finger went up to the second knuckle. After
10 minutes the client
was told by the family member to turn to the right side and the
client did this. What is the
appropriate comment for the nurse to make?
A) Why don’t we now have the client turn back to the left side.
B) That was done correctly. Did you have any problems with the
insertion?
C) Let’s check to see if the suppository is in far enough.
D) Did you feel any stool in the intestinal tract?
The correct answer is B: That was done correctly. Did you have
any problems with the
insertion?
A client with a diagnosis of Methicillin resistant Staphylococcus
aureus (MRSA) has
, died. Which type of precautions is the appropriate type to use
when performing
postmortem care?
A) airborne precautions
B) droplet precautions
C) contact precautions
D) compromised host precautions
The correct answer is C: contact precautions
A nurse administers the influenza vaccine to a client in a
clinic. Within 15 minutes after
the immunization was given, the client complains of itchy and
watery eyes, increased
anxiety, and difficulty breathing. The nurse expects that the first
action in the sequence of
care for this client will be to
A) Maintain the airway
B) Administer epinephrine 1:1000 as ordered
C) Monitor for hypotension with shock
D) Administer diphenhydramine as ordered
The correct answer is B: Administer epinephrine 1:1000 as ordered
.
Which of these children at the site of a disaster at a child
day care center would the
triage nurse put in the "treat last" category?
A) An infant with intermittent bulging anterior fontanel
between crying episodes
